Effect of the Mchinji Social Cash Transfer Pilot Scheme on Children's Schooling, Work and Health Outcomes: A Multilevel Study using Experimental Data

This dissertation examines whether the Mchinji Social Cash Transfer Pilot Scheme (SCTPS), implemented in a rural district in central Malawi, improved schooling, work and health outcomes for children ages 6-17. Effects of individual level (orphan status and child's gender) and household level factors (working-age adults and sick adults) on the outcomes are also studied. The study uses panel data collected in 2007-2008 from a randomized controlled evaluation study. This dissertation is unique in its use of multilevel methods. Also, this is the first study to report on the impact of an unconditional cash transfer program on health outcomes for school-age children. The first paper shows that the Mchinji SCTPS increased school enrollment, decreased days missed from school and reduced children's time spent in economic work activities. Although, transfers increased the number of and time spent in domestic work activities, the number of hours worked remained relatively low. While girls were more advantaged in education they were disadvantaged in child work compared to boys. A larger number of working-age adults in a household was associated with reduced work burden on children. Contrary to other research, orphans in this study were not disadvantaged in schooling and work outcomes relative to non-orphans. The second paper shows that compared to children in non-beneficiary households, those in beneficiary households had lower odds of child illness and serious illness that stopped normal activities. An increase in the household number of working-age adults was associated with lower odds of child illness and health care use. An increase in the household number of sick adults increased the odds of child illness, serious illness and health care use. No statistically significant differences were observed by orphan status and child's gender. Study findings suggest that unconditional programs have the potential to improve outcomes for older children in sub-Saharan Africa. Further research is needed to understand the causal pathways or mechanisms through which Mchinji SCTPS impacts children's outcomes. Going forward, in addition to poverty, unconditional cash transfer programs in Malawi and other sub-Saharan countries should consider other factors that reflect household vulnerabilities or constraints as eligibility criteria, such as adult morbidity.Doctor of Philosoph

Does Venue of HIV Testing and Results Disclosure in the Context of a Research Study Affect Adolescent Health and Behavior? Results from a Study in Western Kenya

Ethical concerns about risks to minor adolescents participating in HIV prevention research is a barrier to their inclusion. One concern is whether HIV testing and results disclosure venue affects the health and behavior of adolescent participants. We assessed for differential effects on quality of life (QOL), depressive symptoms, and sexual behavior due to (1) testing venue (home or health facility) and (2) test result (HIV-positive, HIV-negative, indeterminate). We collected data at three timepoints (baseline, 2-month follow-up, 12-month follow-up) from 113 Kenyan adolescents aged 15–19 (51% female). We analyzed the data using linear mixed effects models for the QOL and depressive symptoms outcomes and a logistic model for the sexual behavior outcome. Results showed a small mental health benefit for adolescents tested for HIV at a health facility compared with home. There was little evidence that testing venue influenced sexual behavior or that test results moderated the effects of HIV testing across all outcomes. The decision to conduct HIV testing at home or a health facility may not be very consequential for adolescents’ health and behavior. Findings underscore the need to critically examine assumptions about adolescent vulnerability to better promote responsible conduct of HIV prevention research with youth in sub-Saharan Africa

Changes in Mental Health, Emotional Distress, and Substance Use Affecting Women Experiencing Violence and Their Service Providers during COVID-19 in a U.S. Southern State

Research conducted during the COVID-19 pandemic has revealed many unintended consequences of mandated safety precautions, including increased perpetration of intimate partner violence (IPV), increases in substance use, and worsening mental health conditions. We conducted a repeated, cross-sectional survey of survivors of IPV, a longitudinal survey of service providers working in an IPV shelter, and interviews with both. We conducted surveys at the beginning of the pandemic and nearly half a year later to assess mental health and, for clients, substance use. Results showed that two small samples of survivors living in the shelter in 2020 and 2021 experienced both mental health decline and increased use of substances. Qualitative data from in-depth interviews suggest that COVID-19-related restrictions mirrored survivors’ experiences of power and control in violent relationships. Further, IPV service providers—essential workers during COVID-19—experienced stress associated with reports of burnout and mental fatigue. This study suggests that community-based organizations can help mitigate the impacts of COVID-19 on survivors of IPV but should avoid adding additional work for staff as service providers experienced mental and emotional stress

Changes in Mental Health, Emotional Distress, and Substance Use Affecting Women Experiencing Violence and Their Service Providers during COVID-19 in a U.S. Southern State

Research conducted during the COVID-19 pandemic has revealed many unintended consequences of mandated safety precautions, including increased perpetration of intimate partner violence (IPV), increases in substance use, and worsening mental health conditions. We conducted a repeated, cross-sectional survey of survivors of IPV, a longitudinal survey of service providers working in an IPV shelter, and interviews with both. We conducted surveys at the beginning of the pandemic and nearly half a year later to assess mental health and, for clients, substance use. Results showed that two small samples of survivors living in the shelter in 2020 and 2021 experienced both mental health decline and increased use of substances. Qualitative data from in-depth interviews suggest that COVID-19-related restrictions mirrored survivors’ experiences of power and control in violent relationships. Further, IPV service providers—essential workers during COVID-19—experienced stress associated with reports of burnout and mental fatigue. This study suggests that community-based organizations can help mitigate the impacts of COVID-19 on survivors of IPV but should avoid adding additional work for staff as service providers experienced mental and emotional stress

Does Venue of HIV Testing and Results Disclosure in the Context of a Research Study Affect Adolescent Health and Behavior? Results from a Study in Western Kenya

Ethical concerns about risks to minor adolescents participating in HIV prevention research is a barrier to their inclusion. One concern is whether HIV testing and results disclosure venue affects the health and behavior of adolescent participants. We assessed for differential effects on quality of life (QOL), depressive symptoms, and sexual behavior due to (1) testing venue (home or health facility) and (2) test result (HIV-positive, HIV-negative, indeterminate). We collected data at three timepoints (baseline, 2-month follow-up, 12-month follow-up) from 113 Kenyan adolescents aged 15–19 (51% female). We analyzed the data using linear mixed effects models for the QOL and depressive symptoms outcomes and a logistic model for the sexual behavior outcome. Results showed a small mental health benefit for adolescents tested for HIV at a health facility compared with home. There was little evidence that testing venue influenced sexual behavior or that test results moderated the effects of HIV testing across all outcomes. The decision to conduct HIV testing at home or a health facility may not be very consequential for adolescents’ health and behavior. Findings underscore the need to critically examine assumptions about adolescent vulnerability to better promote responsible conduct of HIV prevention research with youth in sub-Saharan Africa

Suicide behaviour among adolescents in a high HIV prevalence region of western Kenya: A mixed-methods study

The study purpose was to determine the prevalence and determinants of suicidal thoughts and behaviours in a rural community sample of 15–19-year-old Kenyan adolescents in a region with high HIV burden. Data were from an observational study examining ethical issues in adolescent HIV research (N=4084). Participants reporting suicidal ideation were assessed for suicide risk. Directed content analyses were conducted using assessment reports. Logistic regression was used to identify factors associated with suicide outcomes. Prevalence of suicidal ideation was 16%. Of these, 38% were low risk and 12% were moderate/high-risk. Females and sexually active adolescents had higher odds of suicidal ideation and being categorised as moderate/high-risk. Adolescents with higher depression scores had higher odds of reporting ideation. Pregnancy was protective for females while impregnating a partner was a risk factor for males. Abuse from a family member, financial stress and health concerns were the most frequently mentioned precipitants of ideation. However, only abuse increased odds of suicide behaviour. Effective programmes to identify and support sexually active, pregnant, and distressed adolescents at risk for suicide are needed. Approaches involving families, schools, health facilities, and community gatekeepers may have the most promise in sub-Saharan African rural areas with limited mental health services